Thursday, November 27, 2014

Chronic rotator cuff tears - how should they be treated?

The Rotator Cuff Quality-of-Life Index Predicts the Outcome of Nonoperative Treatment of Patients with a Chronic Rotator Cuff Tear.

These authors studied ninety-three patients with a documented chronic (defined as symptomatic for 3 or more months) full-thickness rotator cuff tears. These patients averaged 60 years of age and 42% were female. The tears averaged 1.6 cm (in the 60 with imaging) and half had a traumatic onset. Forward elevation averaged 154 degrees and symptoms averaged 28 months in duration.

Patients underwent a three-month supervised program of nonoperative treatment consisting of stretching exercises followed by strengthening exercises when pain and stiffness had subsided.

Treatment was defined as successful if surgical treatment was no longer deemed appropriate by both patient and surgeon because the patient had improved considerably and was predominantly asymptomatic. Treatment was defined as a failure if the patient elected to have surgery after failing to improve and remaining symptomatic.

Rehabilitation was successful in seventy (75%) of the patients. Eighty-nine percent of patients maintained their three-month outcome at two years of follow-up. It is not known if the tear size progressed over the two year time frame.

The preoperative Rotator Cuff Quality-of-Life Index (RC-QOL) score was a significant predictor of outcome.
The results are shown graphically below.

Comment: This is an important article in that it indicates (1) non-operative treatment can be durably successful in the management of small chronic cuff tears and (2) that patients that succeeded with rehabilitative treatment had higher pre-treatment Rotator Cuff Quality-of-Life Index (RC-QOL) scores. In that the cuff tears in this study were chronic, there seems little harm in giving such patients a trial of non-operative management and avoiding surgery in the majority of them that succeed with this program.

While it is sometimes stated that failure of non-operative management is an indication for surgery, it is not obvious that individuals that fail non-operative treatment are good candidates for surgery. Thus it would be most informative if the authors could do a similar study with surgical treatment; it seems likely that patients with low Rotator Cuff Quality-of-Life Index (RC-QOL) scores before surgery will do less well with operative treatment.